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Bill of Rights
Centers
Miami
Madrid
London
Physicians
Fernando J. Bianco, MD
Mark Emberton, MD
Edward L. Gheiler
Juan I. Martinez-Salamanca, MD
Ariel M. Kaufman, MD
Inventories
Health Inventories
QOL
SHIM
IPSS
IIEF-15
EQ5
WPAI
BAPS
RSES
COPS-P
Clinical Trials
Publications
Contact Us
Urological Research Network
URN
home
Bill of Rights
Centers
Miami
Madrid
London
Physicians
Fernando J. Bianco, MD
Mark Emberton, MD
Edward L. Gheiler
Juan I. Martinez-Salamanca, MD
Ariel M. Kaufman, MD
Inventories
Health Inventories
QOL
SHIM
IPSS
IIEF-15
EQ5
WPAI
BAPS
RSES
COPS-P
Clinical Trials
Publications
Contact Us
Inventories
Health Inventories
QOL
SHIM
IPSS
IIEF-15
EQ5
WPAI
BAPS
RSES
COPS-P
Español
General QOL - Quality of Life - Assessment
Answer based on your Sexual and Urinary Function activity over the last 4 weeks ....
Survey Date
*
PatientId
*
Name
First Name
Last Name
Date of Birth
Email
Q1 - Are you having Erections?
*
Yes
No
Q2 - Best Erection_NoMEDS
No Erections (0-10%)
Tumescence (10-40%)
Erection, IC Sometimes (40-60%)
Erection, Sufficient (60-80%)
Erection, Full (80-100%)
Q3 - SHIM_NO_MEDS
SHIM SCORE
Q4 - Are you using CIALIS, LEVITRA, VIAGRA, STENDRA, STAXIN?
No
Viagra
CIalis
Stanxyn
Stendra
Levitra
Q5 - Best Erection_MEDS
No Erections (0-10%)
Tumescence (10-40%)
Erection, IC Sometimes (40-60%)
Erection, Sufficient (60-80%)
Erection, Full (80-100%)
Q6 - SHIM_MEDS
SHIM Score with Medication
Q7 - Do you have a Penile Implant?
No
Yes
Q9 - Best Erections_MUSE_ICI
No Erections (0-10%)
Tumescence (10-40%)
Erection, IC Sometimes (40-60%)
Erection, Sufficient (60-80%)
Erection, Full (80-100%)
Q10 - Do you use a VACUUM Device?
No
Yes
Q11 - Best Erection_VACUUM
No Erections (0-10%)
Tumescence (10-40%)
Erection, IC Sometimes (40-60%)
Erection, Sufficient (60-80%)
Erection, Full (80-100%)
Q12 - Your Ejaculation is
*
Normal
Decreased
Absent
Q13 - Do you leak urine at the time of climax/orgasm - Climacturia
*
No
Rarely
Sometimes
Frecuently
Q14 - How often have you leaked urine? -E1
*
Never or Rarely
Once a week
More than once a week
Once a day
More than once a day
Q15 - Which best describes your urinary control -E4
*
Total Control
Occasional Dribbling
Frequent Dribbling
No Control
Q16 - How many pads or diapers per day do you usually use to control leakage -E5
*
None
One
Two
Three or More
Q17 - Overall, how big a problem has your urinary function been for you - E12
*
No Problem
Very small problem
Small problem
Moderate problem
Big problem
Q18 - IPSS
IPSS or AUA Symptom Score
Q19 - IPSSQOL
Delighted
Pleased
Satisfied
Mixed
Dissatisfied
Unhappy
Terrible
FilledBy
*
PSA Date1
PSA1
Testosterone1
PSA Date2
PSA2
Testosterone2
PSA Date3
PSA3
Testosterone3
PSA Date4
PSA4
Testosterone4
PSA Date5
PSA5
Testosterone5
PSA Date6
PSA6
Testosterone6
Taking Dutasteride, Finasteride, Duodart
No
Yes
On Testosterone replacement therapy
No
Yes
On Androgen Deprivation Therapy (Lupron, Zoladex, ETC)
No
Yes
Thank you!